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Singh S K
Corneal ulcer
Nepal J Ophthalmol 2011;3(5):1-2
Challenges in the management of corneal ulcerSingh SK
Associate Professor and Medical Director,
Biratnagar Eye Hospital, Nepal
Corneal scar due to various corneal diseases is a major cause of
blindness. Its epidemiology encompasses awide variety of infectious
and inflammatory eye diseases (Whitchr et al, 2001). The prevalence
of corneal
blindness varies from country to country and even from one
population to another, depending on many
factors, such as the availability and general standards of eye
care (Smith et a, 1991). In a study from South
India, prevalence of corneal blindness was 0.66 % in at least
one eye, which included 0.10 % prevalence of
corneal blindness in both eyes. Corneal ulceration and trauma
were the two major causes of corneal blindness
in APEDS (R Dandona et al., 2003). In the Nepal blindness
survey, corneal trauma and ulceration were
found to be the second leading cause of unilateral visual loss
after cataract, accounting for 7.9 % of all blind
eyes (Brilliant LB et al, 1985). The prevalence of blindness
worldwide secondary to microbial keratitis is
currently unknown. Recent evidence suggests, however, that
corneal ulceration is a much more common
event than previously recognized and is a major cause of corneal
scarring and visual loss in developing
countries. The incidence of corneal ulceration in Nepal is one
of the highest reported in the world. The
Bhaktapur Eye Study revealed it to be 799 per 100,000 population
per year (Upadhyay et al, 2001), which isseven times higher than in
South India (Gonzales CA et al, 1996), and seventy times greater
than reported in
the USA (Erie JC et al, 1993).
Treatment of corneal ulcer is easier said than done for various
reasons. Usually, the patients affected are
poor people in the developing world (Whitcher et al, 2002) who
are at a higher risk for microbial keratitis
because of their occupational exposure and their inability to
access the existing health care system. In a
study done in the Eastern Region of Nepal, patients
accessibility to eye care services for the treatment of
corneal ulcer was the main barrier to the uptake of eye services
followed by cost, social belief and ignorance
about the disease (Singh S K, 2004-2005). Other barriers
included a distant location of eye care services, no/
poor transportation services, a busy agricultural season, and
late referrals from health centers and private
practitioners.
The location of tertiary eye hospitals and eye departments in
the Terai part of the Eastern Region of Nepalmakes eyecare services
more accessible to the people of this region. A corneal ulcer
patient in the hilly and
mountainous regions has to walk several hours or even days to
catch a bus to reach a tertiary eye care
centre. At the same time, as the transportation cost is more
expensive in the hilly areas, the patient has to pay
more for his travel compared to the people from the Terai region
of the country. People living in the urban
areas of Nepal and from the bordering area of India have better
accessibility to tertiary eye hospitals in
Nepal due to the relatively better conditions of roads, an a
available rail network (in India), and comparatively
cheaper fares for transportation services.
The corneal ulcer patients face both direct and indirect costs
while getting treatment. Indirect costs like the
loss of daily wages of both the patients and their attendants
and direct costs like the cost of medicine and the
expenditure incurred during a long stay in hospital increases
the overall cost of treatment. In a study done in
South India (Ramalingam et al, 1998-1999), belief in traditional
eye medicine and cost were the major
barriers preventing patients from seeking early treatment for
corneal ulcer at eye hospitals. Due to differentbarriers faced by
them, many patients are losing the initial critical period for the
management of corneal
abrasion/ ulcer and are accessing some harmful forms of
treatment.
The main barrier from the service provider group for corneal
ulcer management is lack of diagnostic facilities.
In the Eastern Region of Nepal, with a population of over 5
million, the facility for culture for corneal ulcer
patients exists only at the eye department of the B P Koirala
Institute of Health Sciences in Koshi Zone.
None of the other tertiary eye hospital have laboratory
facilities with the availability of culture and sensitivity
tests for the management of corneal ulcer. The existing
laboratory facilities in different government health
institutions (health posts, health centers, district hospitals,
and zonal hospitals) are not utilized for the
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Singh S K
Corneal ulcer
Nepal J Ophthalmol 2011;3(5):1-2
management of corneal ulcers because of the lack of ophthalmic
manpower. Additionally, the lack of training
for the existing health manpower in government health care
centers is a significant factor resulting in the
improper management of corneal ulcers. There is also a lack of
co-ordination between existing government
health structures and eye-care infrastructures run by
non-governmental organizations.
Cataract oriented eye programs, the large number of cataract
patients, and a relatively low number of
corneal ulcer patients in the existing tertiary eye hospitals
could be the factors responsible for the lack of
development of laboratory facilities in these hospitals. An
ample cataract population, a greater interest of
ophthalmic surgeons in strengthening their cataract surgery
skills could be the reasons for ophthalmologists
being more interested in doing cataract surgeries and having
both less interest and less time for the management
of corneal ulcers in some hospitals. The same reasons may apply
to hospital administration people being less
interested in the development of facilities for management of
corneal ulcers. In many developing countries,
because of the emphasis on the cataract backlog, a programme
dealing with other causes of blindness has
been neglected (Dandona L et al, 1988). Probably the same is
true in Nepal as well.
It is advisable that a combined approach be made with efforts of
all the stakeholders of eye-care in the
region to minimize the stubborn prevalence of corneal blindness
in general and of corneal ulcer in particular.
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Source of support: nil. Conflict of interest: none
